Gee Whiz: as they say. I could, with a shove, accept that ATSB and CASA have a huge amount of skin in the Pel-Air game and there is a pressing need to defend their stance. Although how they expect anyone who can read and do ‘joined up’ writing to acquiesce to the current line of fable is just a little outside of my comprehension range.

I wonder how many have actually done the ‘reading’ and joined up the rather large red dots? The dots which can only lead to one, inescapable conclusion – someone was telling fairy stories to a Senate inquiry – well; in my opinion at least they were (for what that’s worth). In the beginning, there was a ‘parallel’ investigation. An almost unprecedented move. As part of that ‘investigation’ the weather forecasts, related to the journey were requested by the AILU (White) and received; so far, so good.

Where one of several wheels come off is when White (whether by accident or design, we don’t as yet know) declares that given the ‘available’ weather information (intimating that the aircrew ignored it) is a 'no brainer' guilty verdict - unimpeachable - what he fails to mention that they (the forecasts) were never transmitted.

Now then, picture yourself sitting in a quiet dark cockpit approaching a ‘critical decision point’ you glance at the clock, nudge sleeping beauty awake and say, something along the lines of “what’s the latest at Kickinatinalong (KATA)?” – “Dunno” mutters Sleeping Beauty “didn’t you get the latest?” “Nothing heard; they’re late – busy on HF tonight” you say – “stir ‘em up and see what’s what – PNR in 10 minutes”. With a little persistence, on the busy night time HF – eventually someone will check the fax and trot out the latest for KATA – then after a moment or three – “there’s an amended for KATA, you want it?”. “Oh yes please” say the crew. About four minutes later the aircraft is diverted to an acceptable alternate aerodrome. That is what happens in reality, when a forecast has not been relayed.

There are some perfectly acceptable reasons for an amended or even a routine forecast not being passed along; well, there are, it happens – no sweat if the operating crew are ‘on the ball’. This Pel-Air crew were lost in the Twilight Zone of fatigue and complacency; they should have known better, but much like the Lockhart crew they had been deserted and left to fend for themselves by the system, their operations manual, their C&T systems and the company – all under CASA ‘approval’ (acceptance if you want to split the hair).

As far as the Pel-Air crew was concerned everything was ‘groovy’ – routine and no problemo. Had the 0739 and the 0803 reports been passed, matters would have turned out differently - alas.

So much for the flight crew – bit players – they ditched, the rest is history and old hat

What has never been examined is why White (MAILU) melded the weather reports not transmitted into the ‘CAIR 09/3’ travesty. It is (IMO) designed to be read as though the weather reports had been relayed – part of the transcript etc. Which, in turn, begs the question why did CASA persist to support their claims of gross pilot error, through a Senate inquiry? That, boys and girls requires some bloody strong motivation – it was hellish risky. Had there been a quiet withdrawal to a ‘mediated’ ground, such as. “It has come to our attention that that two crucial weather updates were never received by the flight, this, whilst casting some doubt over crew procedures and flight conduct, provides enough grounds to withdraw ‘administrative action’ against the captain." " We as the safety authority, will be conducting an in depth audit of the company procedures, SOP and training”. Fair, yes; reasonable, yes; acceptable, responsible action from the ‘authority’: yes.

But why, in the light of evidence CASA had before them did they continue to try and avoid the real issues?

But why, in the light of evidence CASA had before them did they do one of the slickest, quickest audits and acquittal of RCA in the history of this planet?

But why, in the light of evidence CASA had before them did they continue and persist in trying to convince a Senate investigation that ‘they’ had the right of it?

But why, in the light of evidence CASA had before them did they continue to embroil the ATSB is this nasty little pantomime?

But why, in the light of evidence CASA had before them did they continue; and, to this day continue, to try and lay all the blame on the flight crew?

Albo washed his hands and turned the dogs loose; Truss tried and ended up with the ASRR which is now an officially ‘forgotten’ document – deemed an inutile opinion. Chester has trouble tying his boot laces without ‘advice’. Three ministers, two governments and CASA just keep on rollin’ along.

I could, I suppose, put it all in simple terms – porky pies have been told– lots of ‘em; the last being the invisible manning’s 531 page edifice which almost, but not quite, fools most of the people, most of the time.

Senators, they are taking the Mickey along with the money and laughing their collective tits off – Hood included. The canary who owns the coal mine, provided he don’t sing. Land rights for gay whales and icebergs in the Yarra don’t signify; not when the integrity and intelligence of a Senate committee is being used to wipe big smiles off smug faces.

P2 has, in some nicely summed up factual data, laid all of this out for you; get one or two of the bright young things to hunt it down and bring it to an end. Before it’s all too little; too late.

Toot (last translation ever) toot. Do try to keep up…….Sandy - Thank you K, your succinct and balanced dissertation nails it perfectly. Nails it with precision and judgment. The two young crew members were brainwashed into believing that the system is so rigorous and all encompassing that it looks after just about every contingency, including passing on crucial information. A system based on fear of the all powerful independent regulator CASA. A system deliberately designed to cower and stultify the untrustworthy scoundrels that recklessly take the unsuspecting into the fearful skies. A system that is not a partnership of responsible equals, but a master and slave system full of strict liability traps with outrageously excessive penalties. A system which is, perversely or inadvertently, aligned to favour the cunning and unscrupulous over the fair and conscientious.

Top post and totally agree Sandy, K unfortunately has taken on the undesirable task of deciphering my research discoveries, ramblings, observations etc. and without exception has been able to translate to at least a level that the average punter can understand...

Now that we are getting to the pointy end of this horrendous tale of unbelievable political/bureaucratic obfuscation, conflict of interest, malfeasance, corruption and self-serving public servant arse covering; I have decided it is about time we re-visited the PelAir chronology/timeline...

"...Senators, they are taking the Mickey along with the money and laughing their collective tits off – Hood included. The canary who owns the coal mine, provided he don’t sing..."

Based on recent FOI information, combined with many, many more factual dots, dashes and educated analogy I believe the final PelAir portrait will overwhelmingly prove that this sad and sick 8+ year episode in Australian aviation safety history should be properly and independently investigated and prosecuted ASAP -

– 30/11/2017:18 November 2009: Ditching 3 NM south-west of Norfolk Island Aerodrome.18 November 2009: ATSB notified of accident and ATSB subsequently notify CASA. TheATSB decide to carry out an investigation and CASA decide to run a parallelinvestigation, initiated 19 November.19 November 2009: Pel-Air voluntarily suspend Westwind operation.20 November 2009: Quote from page 97 of PelAir MKII Final report - "The ATSB asked CAAF for ATS records for the flight and the weather information that was provided to the flight crew of VH-NGA. CAAF forwarded the request to the ATS provider and then obtained the records in December 2009 to pass on to the ATSB. This included copies of the 0630 METAR, 0800 SPECI and 0830 SPECI."

23 November 2009: Richard White MALIU correspondence to ATSB Director Aviation Safety Investigations, Ian Sangston notifying CASA will be conducting a regulatory investigation into the actions of the flightcrew. Note that there is no reference to 'parallel investigations' under either the 2004 or 2010 MOU (ref link - #122 & #28).23 November 2009: Richard White receives from Airservices Australia the complete list of Norfolk Island Terminal Aerodrome Forecasts (TAFs) applicable to the occurrence flight timeframe. This included the Nadi non-relayed 0803 AMD TAF, which appears to be underlined (ref link - #122 & #85 )25 November 2009: Greg Hood file note email (cc'd Jonathon Aleck, Terry Farquharson, John McCormick.). File note No.4 reference to flight recorder recovery would appear to show, at that point in time, that recovery was inevitable (ref link - #125 )26 November 2009: CASA initiate a ‘Special Audit’ conducted between the 26/11/2009-15/12/2009 at the Pel-Air Bases in Sydney, Adelaide and Nowra.7 December 2009: Audit team meet with Pel-Air management to discuss a number ofdeficiencies within the Westwind Operation. This was backed up by correspondence fromCASA on 9/12/2009.8 December 2009: E-mail from ATSB to CASA raising the possibility of contributing to ajoint fund sharing arrangement to recover the black box and CASA advised they didn’thave the necessary funds.16 December 2009: CASA accept the Pel-Air ‘Management Action Plan’ which consistedof three phases.18 December 2009: Pel-Air successfully completed Phase 1 items and were able torecommence domestic operations.23-24 December 2009: CASA overseeing FOI of Pel-Air Eric Demarco issues 14 RCA anda number of AO. The RCAs needed to be acquitted by 28/01/2010.24th December 2009: Dominic James notice of suspension of CPL, ATPL, CIR pursuantto CAR 265(1)(a). Also given notice to undertake examinations under CAR 5.38.24 December 2009: Pel-Air successfully completed Phase 2 items and were able torecommence international operations.8 January 2010: CASA issue 7 more RCAs and several more AO, all of which RogerChambers the Audit Coordinator signed on behalf of several SAR team members.8 January 2010: Audit Report completed.3 February 2010: Video conference meeting between the ATSB and CASA to discusscritical safety issue.12 February 2010: Mr R White ALIU Manager contacts Mr Michael Watson the ATSB‘investigator in charge’ to request a supporting letter that described the critical safetyissue.26 February 2010: Mr Sangston Director of Aviation Safety Investigations writes to MrWhite addressing the critical safety issue with the requested supporting documentation.19 March 2010: CASA LSD draw up and distribute ‘AT10-23 NORFOLK ISLAND SAFETYISSUE LEGAL DRAFT 19 MARCH.doc’.20 March 2010: CASA internal e-mail that highlighted a 50:50 split within the CASAinspectorate on when to divert to an alternate.23 March 2010: ‘AT10-23 NORFOLK ISLAND SAFETY ISSUE LEGAL DRAFT 19MARCH.doc’ approved for Mr White to send by CASA Corporate Relations and Strategy(i.e. Grima and co).23 March 2010: Dominic James licenses cancellation matter (CAR 265(1) (a)) wasoriginally set down for mention in the AAT.26 March 2010: Mr White and CASA initial response to critical safety issue.31 March 2010: ATSB e-mail Mr White ALIU Manager requesting information under S32on Pel-Air’s Air Ambulance classification of Operations and Noumea French regulatorrestrictions on Pel-Air Operations. Note: There is no record/copy of this e-mail.14 April 2010: Mr White’s replies to ATSB e-mail 31 March 2010. Reference SenateInquiry page under ‘Additional information’ item 3.22 April 2010: Follow-up meeting between ATSB and CASA (John Grima and co) on theCSI matter was held in CASA’s Woden, ACT offices. Reference AQON 22/10/12 ATSB(Hansard, pg 66).15 June 2010: ATSB receive e-mail from Pel-Air detailing actions done in response toCASA Special Audit.21 July 2010: CAIR 09/3 completed.28 July 2010: Quote from TSBC peer review report - "On 28 July 2010, CASA briefed the ATSB on the findings of its regulatory investigation into the ditching, which it had done in parallel with the ATSB investigation. Footnote 12The team leader obtained a copy of the CASA investigation report in March 2011."March 2011: (see 28 July 2010 ref above)11 November 2011: Former Pel-Air Chief Pilot and recently appointed CASA FOI(February 2011) Mr. Wickham participates (observer) in a CASA approval process for aPel-Air Check Pilot. Note: Wickham originally applied for a position with CASA as a FlightTraining Examiner in August 2010.13 January 2010: ATSB issue preliminary report AO-2009-072.26 March 2012: Mr Sangston approves Final Report draft release to the directly involvedparties (DIP) for comment on its factual accuracy. Comments were requested from DIPby 23 April 2012.16 July 2012: Draft 2 issued to DIP.4 July 2012: The ATSB requested a copy of the CASA special audit report under asection 32 notice. A copy of the report was received on 9 July 2012.8 August 2012: Flight Nurse Karen Casey submits an FOI request with CASA FOI LegalServices Division asking for a copy of the CASA Special Audit Report.16 August 2012: ATSB Commission approve s25 release of Final Report AO-2009-072and officially reclassify the ‘safety issue’ to minor.30 August 2012: ATSB Final Report AO-2009-072 released.31 August 2012: Final Report amended and re-issued.3 September 2012: 4 Corners ‘Crash Landing’ program goes to air 8:30pm.12 September 2012: E-mail chain (Carmody and Dolan) discussing Senator Xenophon’sproposal for a possible Senate Inquiry into the ATSB Final report AO-2009-072 (thetendentious bloggers e-mail).13 September 2012: Senate referred the Aviation Accident Investigations (Pel-Air) tothe Senate Standing Committees on Rural and Regional Affairs and Transport for inquiryand report.26 September 2012: CASA FOI and Finance officer (LSD) Jennifer Smith-Robertsreleases a redacted version of the CASA SAR to Karen Casey.26 September 2012: RRAT committee request ATSB for documents to assist thecommittee with its inquiry.3 October 2012: Reply from ATSB (Dolan) to committee correspondence requestingdocumentation.19 October 2012: ATSB send RRAT Committee correspondence and attachment inresponse to submissions from Aherne, Quinn and Currall, which had been approved bythe committee to be publicly available.22 October 2012: First Public Hearing for Senate ‘Aviation Accident Investigations’Inquiry.

– 30/11/2017:18 November 2009: Ditching 3 NM south-west of Norfolk Island Aerodrome.18 November 2009: ATSB notified of accident and ATSB subsequently notify CASA. TheATSB decide to carry out an investigation and CASA decide to run a parallelinvestigation, initiated 19 November.19 November 2009: Pel-Air voluntarily suspend Westwind operation.20 November 2009: Quote from page 97 of PelAir MKII Final report - "The ATSB asked CAAF for ATS records for the flight and the weather information that was provided to the flight crew of VH-NGA. CAAF forwarded the request to the ATS provider and then obtained the records in December 2009 to pass on to the ATSB. This included copies of the 0630 METAR, 0800 SPECI and 0830 SPECI."23 November 2009: Richard White MALIU correspondence to ATSB Director Aviation Safety Investigations, Ian Sangston notifying CASA will be conducting a regulatory investigation into the actions of the flightcrew. Note that there is no reference to 'parallel investigations' under either the 2004 or 2010 MOU (ref link - #122 & #28).23 November 2009: Richard White receives from Airservices Australia the complete list of Norfolk Island Terminal Aerodrome Forecasts (TAFs) applicable to the occurrence flight timeframe. This included the Nadi non-relayed 0803 AMD TAF, which appears to be underlined (ref link - #122 & #85 )25 November 2009: Greg Hood file note email (cc'd Jonathon Aleck, Terry Farquharson, John McCormick.). File note No.4 reference to flight recorder recovery would appear to show, at that point in time, that recovery was inevitable (ref link - #125 )26 November 2009: CASA initiate a ‘Special Audit’ conducted between the 26/11/2009-15/12/2009 at the Pel-Air Bases in Sydney, Adelaide and Nowra.30 November 2009: Richard White email to John Barr (cc Roger Chambers) confirming Airservices passed on weather & received flight plan details from PIC Dominic James by phone in Apia. (ref link - #122 ) 7 December 2009: Audit team meet with Pel-Air management to discuss a number ofdeficiencies within the Westwind Operation. This was backed up by correspondence fromCASA on 9/12/2009.7 December 2009: FAA/ICAO brief on 'next steps' after poor results/findings in the ICAO USOAP 2008 Australian audit. (ref links - #53 & WikiLeaks cable PDF: http://auntypru.com/wp-content/uploads/2...ileaks.pdf8 December 2009: E-mail from ATSB to CASA raising the possibility of contributing to ajoint fund sharing arrangement to recover the black box and CASA advised they didn’thave the necessary funds.16 December 2009: CASA accept the Pel-Air ‘Management Action Plan’ which consistedof three phases.16 December 2009: Dominic James was 'informally' interviewed by CASA legal and investigative officers. (ref link - #112 )18 December 2009: Pel-Air successfully completed Phase 1 items and were able torecommence domestic operations.23-24 December 2009: CASA overseeing FOI of Pel-Air Eric Demarco issues 14 RCA anda number of AO. The RCAs needed to be acquitted by 28/01/2010.24th December 2009: Dominic James notice of suspension of CPL, ATPL, CIR pursuantto CAR 265(1)(a). Also given notice to undertake examinations under CAR 5.38.24 December 2009: Pel-Air successfully completed Phase 2 items and were able torecommence international operations.8 January 2010: CASA issue 7 more RCAs and several more AO, all of which RogerChambers the Audit Coordinator signed on behalf of several SAR team members.8 January 2010: Audit Report completed. 1 February 2010: Quote from TSBC report ".. the team leader and the general manager (GM) decided to provide CASA with a briefing on the perceived safety issue. The briefing was held by video conference on 03 February 2010. On 12 February, the primary contact at CASA followed up with a phone call to the IIC asking the ATSB to send a letter describing the safety issue.(ref link - 3 February 2010: Video conference meeting between the ATSB and CASA to discusscritical safety issue.12 February 2010: Mr R White ALIU Manager contacts Mr Michael Watson the ATSB‘investigator in charge’ to request a supporting letter that described the critical safetyissue.15 February 2010: ATSB create a PDF of the Preliminary Report to forward to ICAO ADREP database office. However it would appear that this PDF copy was not forwarded to ICAO until 10 November 2015. (ref link - #149 & ICAO1 ) Ps The original VH-NGA Final Report was never forwarded to ICAO.26 February 2010: Mr Sangston Director of Aviation Safety Investigations writes to MrWhite addressing the critical safety issue with the requested supporting documentation.19 March 2010: CASA LSD draw up and distribute ‘AT10-23 NORFOLK ISLAND SAFETYISSUE LEGAL DRAFT 19 MARCH.doc’.20 March 2010: CASA internal e-mail that highlighted a 50:50 split within the CASAinspectorate on when to divert to an alternate.23 March 2010: ‘AT10-23 NORFOLK ISLAND SAFETY ISSUE LEGAL DRAFT 19MARCH.doc’ approved for Mr White to send by CASA Corporate Relations and Strategy(i.e. Grima and co).23 March 2010: Dominic James licenses cancellation matter (CAR 265(1) (a)) wasoriginally set down for mention in the AAT.26 March 2010: Mr White and CASA initial response to critical safety issue.31 March 2010: ATSB e-mail Mr White ALIU Manager requesting information under S32on Pel-Air’s Air Ambulance classification of Operations and Noumea French regulatorrestrictions on Pel-Air Operations. Note: There is no record/copy of this e-mail.14 April 2010: Mr White’s replies to ATSB e-mail 31 March 2010. Reference SenateInquiry page under ‘Additional information’ item 3.22 April 2010: Follow-up meeting between ATSB and CASA (John Grima and co) on theCSI matter was held in CASA’s Woden, ACT offices. Reference AQON 22/10/12 ATSB(Hansard, pg 66).26 May 2010: At a 'regular' meeting between John McCormick (former CASA DAS) and Martin Dolan (former ATSB Chief Commissioner), McCormick advised Dolan that in light of the ongoing PelAir parallel investigation, that CASA would be conducting an internal review of it's audit and surveillance processes.(ref link - #97) 27 May 2010: The Hon Anthony Albanese MP and former Minister for Infrastructure, Transport & Regional Development officially opens the REX Australian Airline Pilot Academy. (ref link - #97) 11 June 2010: Correspondence from CASA ALC (assigned legal counsel) Joe Rule to DJ Legal Counsel in reply to questions asked on the DJ FCL suspension in the lead up to a proposed AAT hearing. This 'answering' correspondence would appear to indicate that CASA LSD were also misled in relation to the 0803 AMD TAF. (ref link - #109 & http://auntypru.com/wp-content/uploads/2....6.101.pdf ) 15 June 2010: ATSB receive e-mail from Pel-Air detailing actions done in response toCASA Special Audit.21 July 2010: CAIR 09/3 completed. 28 July 2010: Quote from TSBC peer review report - "On 28 July 2010, CASA briefed the ATSB on the findings of its regulatory investigation into the ditching, which it had done in parallel with the ATSB investigation.Footnote 12 "The team leader obtained a copy of the CASA investigation report in March 2011."11 January 2011: CASA email chain, initiated by Roger Chambers, on Dominic James CEP (Coordinated Enforcement Process) . Highlights one of the many times the CEP was varied and the senior management ranks that had a vested interest in the PelAir ditching matter. (ref link - #98 )March 2011: (see 28 July 2010 ref above)5 August 2011: With little to no fanfare CASA DAS John McCormick issues a regulatory policy directive ( ref link - #74 & Download das-pn015-2010.pdf) titled "ATSB Cooperation Policy". Appears to be a threat to any CASA Officers not to talk out of school to the ATSB. 11 November 2011: Former Pel-Air Chief Pilot and recently appointed CASA FOI(February 2011) Mr. Wickham participates (observer) in a CASA approval process for aPel-Air Check Pilot. Note: Wickham originally applied for a position with CASA as a FlightTraining Examiner in August 2010.13 January 2010: ATSB issue preliminary report AO-2009-072.26 March 2012: Mr Sangston approves Final Report draft release to the directly involvedparties (DIP) for comment on its factual accuracy. Comments were requested from DIPby 23 April 2012.27 March 2012: CASA Delegate Greg Hood signs a 'notice of variation' & 'notice of revocation' correspondence to Dominic James . This notice was supported by, a Hood signed, Roger Chambers authored 'Standard Form Recommendation'. (ref link - http://auntypru.com/wp-content/uploads/2017/10/FOI4.pdf )30 March 2012: Roger Chambers correspondence to CASA (cast of thousands) officers involved in DJ CEP, notifying for administrative purposes the Hood signed 27 March 2012 notice. (ref link - #98 & #100 ) 30 June 2012: Roger Chambers correspondence to DJ notifying him that omission of the agreed conditions on his FCL is illegal and those conditions will now have to be published on his FCL. This notice gave DJ seven days to respond. (ref link - #103 ) 4 July 2012: The ATSB requested a copy of the CASA special audit report under asection 32 notice. A copy of the report was received on 9 July 2012.16 July 2012: Draft 2 issued to DIP.18 July 2012: Roger Chambers recommendation to add conditions to DJ FCL. Included a Roger Chambers authored SFR that was not signed by CASA Delegate. (ref link - #103 & http://auntypru.com/wp-content/uploads/2017/10/Dominic-James-documents-released-19-Oct-17-Volume-1.pdf )July-Aug 2012: REX Airlines declares political donations of 250K to the ALP; 95.7K to the Nationals; & 40K to the Liberals (ref link - http://www.abc.net.au/news/2016-10-24/ae...le/7959394 & #94)8 August 2012: Flight Nurse Karen Casey submits an FOI request with CASA FOI LegalServices Division asking for a copy of the CASA Special Audit Report.16 August 2012: ATSB Commission approve s25 release of Final Report AO-2009-072and officially reclassify the ‘safety issue’ to minor.30 August 2012: ATSB Final Report AO-2009-072 released.31 August 2012: Final Report amended and re-issued.3 September 2012: 4 Corners ‘Crash Landing’ program goes to air 8:30pm.12 September 2012: E-mail chain (Carmody and Dolan) discussing Senator Xenophon’sproposal for a possible Senate Inquiry into the ATSB Final report AO-2009-072 (thetendentious bloggers e-mail).13 September 2012: Senate referred the Aviation Accident Investigations (Pel-Air) tothe Senate Standing Committees on Rural and Regional Affairs and Transport for inquiryand report.26 September 2012: CASA FOI and Finance officer (LSD) Jennifer Smith-Robertsreleases a redacted version of the CASA SAR to Karen Casey.26 September 2012: RRAT committee request ATSB for documents to assist thecommittee with its inquiry.3 October 2012: Reply from ATSB (Dolan) to committee correspondence requestingdocumentation.10 October 2012: Ten documents, including the infamous Chambers Report, were received (presumably sent anonymously) by the RRAT Committee Secretariat in relation to the Senate AAI Inquiry. However these documents were not formally tabled till the day before the extraordinary 15 February 2013 public hearing. (ref link - #24 ) 19 October 2012: ATSB send RRAT Committee correspondence and attachment inresponse to submissions from Aherne, Quinn and Currall, which had been approved bythe committee to be publicly available.22 October 2012: First Public Hearing for Senate ‘Aviation Accident Investigations’Inquiry.10 November 2015: PDF copy of 2010 AO-2009-072 Preliminary report (Aus_Isreal_VH-NGA_18Nov2009_prelim.pdf) is bizarrely modified and added (2126 days after it was created) to the ICAO iSTAR/ADREP database by the ATSB REPCON Manager Elaine Hargreaves. (ref links - 15 February 2010 entry & #56 + https://blogs.crikey.com.au/planetalking.../17/52003/)30 November 2017: Quote from CASA FOI Officer David Gobbitt correspondence email to Dominic James - "I have not been able to locate a signed copy of the SFR...However, as stated by Adam Anastasi in his email to you dated 27 October 2017, even if the delegate had not signed the SFR, the fact of the delegate sending the decision letter to you on 24 December 2009 would clearly have signified that the delegate accepted the recommendations in the SFR..." (ref - #126 & #331.)

“But, but there’s Choc frog in it for him” P2 muttered: “what’s the hold up?” “You may want to up the ante” say’s P7 “try Ale – works like a charm”. Or so the story goes anyway. Truth is it takes hours to join the dots; do the reading, check the facts and then translate the whole thing into ‘Muggle-speak’. “Can’t do ‘em all at once” says I; P2 nods and say’s “that suits me, if we can just chip away at the pile, it’ll get done”. “Start on the ‘red’s” say’s P7. So it was agreed; each ‘red’ goes to the network – the responses have to be read and the ‘majority opinion’ presented – “Begin at the beginning” said the King of Hearts.

18 November 2009: ATSB notified of accident and ATSB subsequently notify CASA. The ATSB decide to carry out an investigation and CASA decide to run a parallel investigation, initiated 19 November.

What for and why? The last recorded ‘pseudo’ parallel investigation we can find is the ‘Lockhart River’ event; and even that could not be classified a truly parallel. What is ‘passing strange’ is that there was a song and dance about the role CASA played in operational approvals – led to a mighty big inquiry. Nothing of value to industry came of that expenditure. So we must wonder what prompted (goosed some say) CASA to leap into action under the auspices of a not yet operational MOU, under a brand new Manager of such things. It may well be the first ‘parallel investigation’ in the history of Australian aviation. So why the ‘rush’? ATSB would have plodded their way through the event, come up with some form of answer, maybe even hand balled it over to the CASA front row – something along the lines of “look here – we think the pilot broke a rule or two – you blokes want to check it out?”. That would smack of the normal, the routine and reflect past actions. White had James hung, drawn and bloody near quartered before the aircraft was settled on the ocean floor. Interesting in that context - at least when you consider this:-

23 November 2009: Richard White MALIU correspondence to ATSB Director Aviation Safety Investigations, Ian Sangston notifying CASA will be conducting a regulatory investigation into the actions of the flight crew. Note that there is no reference to 'parallel investigations' under either the 2004 or 2010 MOU (ref link - #122 & #28).

It becomes intriguing when you weigh in

20 November 2009: Quote from page 97 of Pel-Air MKII Final report - "The ATSB asked CAAF for ATS records for the flight and the weather information that was provided to the flight crew of VH-NGA. CAAF forwarded the request to the ATS provider and then obtained the records in December 2009 to pass on to the ATSB. This included copies of the 0630 METAR, 0800 SPECI and 0830 SPECI."

Within 24 hours ATSB had the ‘official’ record of the flight information provided by CAA Fiji Nadi (Nandi). The ‘majority’ wonder why the BoM/ Air Services list of ‘available’ weather reports differs from the CAAF version. The 0739 and the 0803 critical forecasts existed, a simple cross check would have begged the questions – why did the flight crew not receive them? Did the Fiji ATC actually receive them? These reports are pivotal – with them the decision to divert became option one; without the information – the flight was doomed.

By Nov 23, 09 White had the complete list of weather reports; it must have been a clear as crystal that the flight never received that crucial information. So why persist; even more intriguing is why this information was tarted up and slipped into a report as being ‘received’? That is was not received is bad enough; but to obfuscate the fact to imply that the reports were made available and ignored by the captain is just a little bit naughty.

There, that should get a seeker of truth going, the links provided by P2 provide some fairly easy to follow bread crumbs. You will need to refer back to Post #31to access those links in the chronology. Having ‘an opinion’ is a thing you are entitled to; having an informed opinion is a thing you need – so they say.

Quote:Lead Balloon #1157 - There is probably no single ‘smoking gun’ to explain the energetic efforts to blame the PIC of NGA alone.

The Mildura event merely exposed dysfunction in BOM (and to some extent the ANSP) and accordingly the regulator. It was mostly luck that there was no hull loss and injuries or fatalities. So pretty easy to use the ‘move on nothing to see here’ tactic.

The coin having fallen the other way on 18 November 2009, the PIC of NGA exposed fundamental flaws in:

- Australia’s Pacific neighbours’ flight services- BOM- Australia’s ANSP- the governance of an external Australian territory- the operations of a politically-connected air operator, and- the regulator’s oversight of the air operator.

This around the time of the FAA audit.

Very, very inopportune circumstances for a pilot to make a mistake. Way too many embarrassments.

The subsequent attempted whitewash managed to expose the increasing dysfunction in the ATSB.

These factors (and Australia’s airport infrastructure) are why Australia’s international reputation is that it is the only third world aviation nation in which you can safely drink the tap water.

Naturally, in the Orwellian world of 21st century government, all these organisations have to pretend that they’re doing a great job and ‘punching above their weight’. FWGJAU!

Coincidentally - purely coincidentally - the governance arrangements for the external Australian territory in question were, subsequent to the ditching, changed, and YSNF coincidentally - purely coincidentally - reappeared in the Area Forecasts for Area 20.

I should note that I’m not criticising any individual. I’m not criticising any individual who provides air traffic control or flight information services, or weather forecasting or reporting services, or individual investigators or operations or airworthiness inspectors. What’s at fault is the busted organisations in which they work - organisations that as a whole are now much less than the sum of their parts.

Check Post 32 – P2 is adding more ‘links’, notes and dates to the chronology of this ‘passing strange’ affair.

Meanwhile:-

`It's the oldest rule in the book,' said the King. Then it ought to be Number One,' said Alice. The King turned pale, and shut his note-book hastily. `Consider your verdict,' he said to the jury, in a low, trembling voice. `There's more evidence to come yet, please your Majesty,' said the White Rabbit, jumping up in a great hurry; `this paper has just been picked up.'

24th December 2009: Dominic James notice of suspension of CPL, ATPL, CIR pursuant to CAR 265(1)(a). Also given notice to undertake examinations under CAR 5.38.

“I have not been able to locate a signed copy of the SFR.”

The immortal words of one D. Gobbit, Esq to Adam Anastasi, CASA FOI specialist. Now then, despite Aleck’s say -so; Carmody agreed with the Senator, it seems ‘reasonable’ that a document suspending; or, at least ‘limiting’ a heavy weight item like a pilot’s licence should be signed off by the officer with the ‘juice’ to do it. I’ve lost track of the number of SFR James has on his sheet, three seems to ring a bell; no matter – it all takes us back to Chambers running the scam and Hood nodding, but not signing. Which leaves us not only looking askance at the McConvict/Chambers game plan, but asking what the devil Hood was about. There seems to be good reason to question the integrity of the whole action against James, right there. Even if it is only to ‘eliminate’ the item from the suspicion list. Chambers seems to have been determined to ensure that all the blame and paperwork landed on the pilot’s head; which is fine – provided it has all been done according to Hoyle. Hood, despite his protests of innocence and sanctimonious ‘reclusive’ stance, was up to his nuts in some glaring unfortunate administrative ‘errors’. If it can ever be proven that Chambers was off the reservation on McConvicts authority and our Hi Viz Canary - Hood knew it; there’ll be hell to pay. There is quite a long list of unsigned or not signed by author documents, RCA and SFR etc. We wonder why?

Meanwhile – back at the coal face:-

7 December 2009 (Monday): Audit team meet with Pel-Air management to discuss a number of deficiencies within the Westwind Operation. This was backed up by correspondence from CASA on 9/12/2009.

What a very ‘interesting’ ten days. Two of them a weekend, which leaves us eight working days. Here is an operation which, in less than a week, managed to answer all the RCA/NCN; have them acquitted and signed off as ‘satisfactory’. Amended operations manuals; FRMS, SMS and international flight protocols, informed flight crew and where required retrained and qualified crew scattered over a few bases - then got it all past CASA – in that short period of time? Bollocks. And anyway – why was Chambers signing the RCA on behalf of the original author? I won’t bang on about this element yet, nor the comparative ‘time-lines’ from other operations beset by CASA RCA. But, for a starter, ask any chief pilot or manager about the time and hassle of acquitting a RCA (NCN) resulting from an audit. There will be much more to follow on this element – standing alone, it’s worth a Senate inquiry – even leaving aside the CASA hiring the chief pilot. But I digress.

8 December 2009: E-mail from ATSB to CASA raising the possibility of contributing to a joint fund sharing arrangement to recover the black box and CASA advised they didn’t have the necessary funds.

This is an interesting part – for the connoisseur of puzzles. Remarkable thing this flat refusal to collect the CVR and FDR. Even if it was an old one with the last 30 minutes of the flight recorded – it was deemed to be irrelevant by Dolan (ATSB), this fully supported by McComic (CASA). This, despite the fact that both ATSB & CASA, both knew ‘the box’ was a newer version and held 120 minutes of data. “Can’t afford it” they mewled together. Hells Bells McConvict spent almost that much, a month, keeping the lovely Libby, then Industry Complaints Commissioner (ICC) in chocolates and champagne. This one, singular aberration typifies, more than any other the determination to force a preordained result into conclusion and fact. In the beginning, the Norfolk locals would have raised the CVR for little more than the price of a carton of beer(Norfolk tourist prices). Gods alone know what the total cost of that CVR recovery is now – when you consider the total cost of a Senate inquiry; plus the total cost of the ASRR, plus the total cost of the TSBC review, plus the cost of a second report. Bloody astronomical.

Easy audit; rapid acquittal, speedy corporate and cultural changes, quickest catch up in flight management and operational procedure/SOP in the history of aviation and the slowest ever recorded retrieval of a critical ‘Black box’ from shallow, still, warm, sunlit waters.

Forget about the aircrew – focus on what Chambers and his merry band of sidekicks were playing at; define why. Then think on the Senate inquiry and ask why, to what end and purpose did ATSB and CASA face down and try to bluff their way out of it; particularly when not only was the simple truth was in their hands, but many alternate escape paths were available.

Aye; ours is not reason why; but we do. We also know that the FAA auditors would not give a flying fundamental about the ditching ‘incident’ in relation to their audit of Australian aviation. But, they may pay a little more attention to this disgraceful shambles and expense foisted on the public purse, next time they visit.

Quote:The coin having fallen the other way on 18 November 2009, the PIC of NGA exposed fundamental flaws in:

- Australia’s Pacific neighbours’ flight services- BOM- Australia’s ANSP- the governance of an external Australian territory- the operations of a politically-connected air operator, and- the regulator’s oversight of the air operator.

The LB ‘list’ of fundamental flaws is particularly useful up to the point of impact. The holes in the safety net are exposed and, IMO, form a great part of the causal chain. Had those areas of interest been the subject of the Senate inquiry, we may have seen some ‘reform’ of the system to mend the net. The short list of ‘system’ flaws, properly addressed, is a good place to start reform – from an air safety perspective. There would be a gold star from an external auditor if these matters were ‘sorted’, particularly if the agencies concerned could say ‘hand on heart’ that they identified and corrected these deficiencies without prompting or ministerial involvement; part of a developing improving safety culture. Alas. Up went the drawbridge, out came the defenders armed with denial and obfuscation. This is bad enough and typifies the Hedgehog like defence mechanisms automatically deployed when a ‘threat’ is nearby.

It reminds me of the old WWII tale, told by an Uncle who flew during that dreadful conflict. When aircraft returned from a mission – shot full of holes, the ‘engineers’ not only repaired the damage but added additional armour plating to the damaged area. Nothing changed; the aircraft which returned still had holes shot in them, in roughly the same places. This went on until some bright spark said “it’s the ones which are not returning we need to examine; that will tell us where to reinforce”. Well, seems they had a look at a few lost aircraft and began putting the ‘armour’ in the vulnerable places, the places which cost lives and machinery. Immediate improvement – lesson learnt. No one got blamed or denigrated; they were all too busy and pleased to be able to reduce losses. Seems to me like a bloody good place to start an overhaul of ‘service’ to industry.

If you continue along LB’s line (as you must) then the next step involves the handling of the Norfolk debacle by ATSB and CASA. The extraordinary behaviour of the ‘Bankstown’ crew and management; after the event, does little in the way of begging for answers – it stridently demands those answers. The aircrew are being used as a focus point, bait for the ‘looky-loo’s’. This distracts attention away from the almost incredible behaviour of upper, middle and low level management. The Pel-Air operation was almost a basket case, sliding along mostly on luck, benign weather and ‘derring-do’. A protected species, there is no audit trail showing where CASA brought deficiencies to the attention of ‘management’. There is no record of extensive, progressive amendments to the company operations manual supporting the changes in operational dynamics. There is no record of ‘international’ operations being a recognised risk area nor of a progressive maturing of both system and guidance, let alone education. Hells bells, Pel-Air could not even address the demands of the French authority; choosing instead to let it be known to ‘avoid’ Noumea whenever possible – even if not possible…..

If and it is a big IF, the Senate committee ever decide to take another look at the Pel-Air debacle it should focus on the behaviour of ‘the regulator’ throughout not only this disgraceful episode, but of several ‘other’ bizarre events which, IMO demand answers. There are many strange tales told from across the wide, brown land of CASA behaviour; some are likely to be true – but non so strange as the tale of Wodger and his merry band of misfits.

Not that any of this matters anymore than a Tinkers curse. The minister will return to his man-scaping activities; St Carmody will pour oil on troubled waters, Aleck will continue to confound and confuse; the rest will simply sit back, do as they are directed, count their super and wait for the opportunity to extract pay-back, from those who dare to mention how severely ducked up CASA is, in reality. So don’t say word children – lest the bogey –man turn up at your next audit. “Is he really real?” asks one of innocent faces “Yes child, I’m afraid he is”.

“I am not even prepared to meet Professor Einstein or Bertrand Russell; why should I vaingloriously assume that God would find me interesting? (Robertson Davies).

Quote:26 May 2010: At a 'regular' meeting between John McCormick (former CASA DAS) and Martin Dolan (former ATSB Chief Commissioner), McCormick advised Dolan that in light of the ongoing PelAir parallel investigation, that CASA would be conducting an internal review of it's audit and surveillance processes.(ref link - #97) 27 May 2010: The Hon Anthony Albanese MP and former Minister for Infrastructure, Transport & Regional Development officially opens the REX Australian Airline Pilot Academy. (ref link - #97) July-Aug 2012: REX Airlines declares political donations of 250K to the ALP; 95.7K to the Nationals; & 40K to the Liberals (ref link - http://www.abc.net.au/news/2016-10-24/ae...le/7959394 & #94)

Of particular interest was Rex’s $250,000 donation to the federal ALP given the airline was a highly vocal critic of the Labor government.

In 2013 Rex publicly said the ALP was “hellbent” on destroying regional aviation and “along with it pretty much the rest of the economy”.

Mr Xenophon said it appeared to defy reason why Rex would donate heavily to a government it would shortly afterwards describe as “destroying its industry”.

“Perhaps Rex had a case of Stockholm syndrome?” he said.

In 2009 a Rex aeroplane — operated under the group’s Pel-Air brand — ditched into the ocean with six passengers on board, badly injuring one.

A lengthy Australian Transport Safety Board investigation blamed the Pel-Air pilot involved in the crash but failed to mention 57 breaches or “serious deficiencies” at Pel-Air.

Mr Xenophon headed a Senate committee inquiry into that botched investigation, which led to the federal government last month calling on the ATSB to reopen the investigation.

Given the recent MSM coverage on certain Chinese political influences and donations I was interested to review the ABC's coverage of the AEC 2015-16 list of political donations. From that I was only able to find one donation from REX Regional Express Airlines: http://www.abc.net.au/news/2017-02-01/au...16/8208090

– 30/11/2017:23 September 1999: Qantas Flight 1 overshoots runway at Bangkok. (ref - #221 & https://www.atsb.gov.au/publications/investigation_reports/1999/AAIR/aair199904538.aspx )11 March 2003: 2nd phase of cooperative Qantas/CASA/University of SA FRMS study.(see links above & https://www.flightglobal.com/news/articl...on-162972/)18 November 2009: Ditching 3 NM south-west of Norfolk Island Aerodrome.18 November 2009: ATSB notified of accident and ATSB subsequently notify CASA. TheATSB decide to carry out an investigation and CASA decide to run a parallelinvestigation, initiated 19 November.19 November 2009: Pel-Air voluntarily suspend Westwind operation.20 November 2009: Quote from page 97 of PelAir MKII Final report - "The ATSB asked CAAF for ATS records for the flight and the weather information that was provided to the flight crew of VH-NGA. CAAF forwarded the request to the ATS provider and then obtained the records in December 2009 to pass on to the ATSB. This included copies of the 0630 METAR, 0800 SPECI and 0830 SPECI."23 November 2009: Richard White MALIU correspondence to ATSB Director Aviation Safety Investigations, Ian Sangston notifying CASA will be conducting a regulatory investigation into the actions of the flightcrew. Note that there is no reference to 'parallel investigations' under either the 2004 or 2010 MOU (ref link - #122 & #28).23 November 2009: Richard White receives from Airservices Australia the complete list of Norfolk Island Terminal Aerodrome Forecasts (TAFs) applicable to the occurrence flight timeframe. This included the Nadi non-relayed 0803 AMD TAF, which appears to be underlined (ref link - #122 & #85 )25 November 2009: Greg Hood file note email (cc'd Jonathon Aleck, Terry Farquharson, John McCormick.). File note No.4 reference to flight recorder recovery would appear to show, at that point in time, that recovery was inevitable (ref link - #125 )26 November 2009: CASA initiate a ‘Special Audit’ conducted between the 26/11/2009-15/12/2009 at the Pel-Air Bases in Sydney, Adelaide and Nowra.30 November 2009: Richard White email to John Barr (cc Roger Chambers) confirming Airservices passed on weather & received flight plan details from PIC Dominic James by phone in Apia. (ref link - #122 ) 7 December 2009: Audit team meet with Pel-Air management to discuss a number ofdeficiencies within the Westwind Operation. This was backed up by correspondence fromCASA on 9/12/2009.7 December 2009: FAA/ICAO brief on 'next steps' after poor results/findings in the ICAO USOAP 2008 & FAA Nov 30- Dec 4 2009 Australian audits. (ref links - #53 & WikiLeaks cable PDF: http://auntypru.com/wp-content/uploads/2...ileaks.pdf8 December 2009: E-mail from ATSB to CASA raising the possibility of contributing to ajoint fund sharing arrangement to recover the black box and CASA advised they didn’thave the necessary funds.11 December: Advice from the UK Civil Aviation Authority to CASA providing an assessment of the fatigue scores for the accidental flight (ref link - #122 & PDF 881KB ) 16 December 2009: CASA accept the Pel-Air ‘Management Action Plan’ which consistedof three phases.16 December 2009: Dominic James was 'informally' interviewed by CASA legal and investigative officers. (ref link - #112 )18 December 2009: Pel-Air successfully completed Phase 1 items and were able torecommence domestic operations. 21 December 2009: CASA Special Audit of Pel-Air Fatigue Risk Management System ( ref links - #217 & PDF 5428KB )23-24 December 2009: CASA overseeing FOI of Pel-Air Eric Demarco issues 14 RCA anda number of AO. The RCAs needed to be acquitted by 28/01/2010.24th December 2009: Dominic James notice of suspension of CPL, ATPL, CIR pursuantto CAR 265(1)(a). Also given notice to undertake examinations under CAR 5.38.24 December 2009: Pel-Air successfully completed Phase 2 items and were able torecommence international operations.8 January 2010: CASA issue 7 more RCAs and several more AO, all of which RogerChambers the Audit Coordinator signed on behalf of several SAR team members.8 January 2010: Audit Report completed.

13 January 2010: ATSB issue preliminary report AO-2009-072. 1 February 2010: Quote from TSBC report ".. the team leader and the general manager (GM) decided to provide CASA with a briefing on the perceived safety issue. The briefing was held by video conference on 03 February 2010. On 12 February, the primary contact at CASA followed up with a phone call to the IIC asking the ATSB to send a letter describing the safety issue.3 February 2010: Video conference meeting between the ATSB and CASA to discusscritical safety issue. 4 February 2010: Internal CASA email ATSB identification of a 'critical safety issue' may have ramification for CASA actions in relation to Mr James (ref links - #217 & PDF 913KB )9 February 2010: Internal ATSB email regarding the ATSB and CASA's approach to the Pel-Air investigation (ref links - #217 & PDF 1093KB )12 February 2010: Mr R White ALIU Manager contacts Mr Michael Watson the ATSB‘investigator in charge’ to request a supporting letter that described the critical safetyissue.15 February 2010: ATSB create a PDF of the Preliminary Report to forward to ICAO ADREP database office. However it would appear that this PDF copy was not forwarded to ICAO until 10 November 2015. (ref link - #149 & ICAO1 ) Ps The original VH-NGA Final Report was never forwarded to ICAO.26 February 2010: Mr Sangston Director of Aviation Safety Investigations writes to MrWhite addressing the critical safety issue with the requested supporting documentation.19 March 2010: CASA LSD draw up and distribute ‘AT10-23 NORFOLK ISLAND SAFETYISSUE LEGAL DRAFT 19 MARCH.doc’.20 March 2010: CASA internal e-mail that highlighted a 50:50 split within the CASAinspectorate on when to divert to an alternate.23 March 2010: ‘AT10-23 NORFOLK ISLAND SAFETY ISSUE LEGAL DRAFT 19MARCH.doc’ approved for Mr White to send by CASA Corporate Relations and Strategy(i.e. Grima and co).23 March 2010: Dominic James licenses cancellation matter (CAR 265(1) (a)) wasoriginally set down for mention in the AAT.26 March 2010: Mr White and CASA initial response to critical safety issue.31 March 2010: ATSB e-mail Mr White ALIU Manager requesting information under S32on Pel-Air’s Air Ambulance classification of Operations and Noumea French regulatorrestrictions on Pel-Air Operations. Note: There is no record/copy of this e-mail.14 April 2010: Mr White’s replies to ATSB e-mail 31 March 2010. Reference SenateInquiry page under ‘Additional information’ item 3.22 April 2010: Follow-up meeting between ATSB and CASA (John Grima and co) on theCSI matter was held in CASA’s Woden, ACT offices. Reference AQON 22/10/12 ATSB(Hansard, pg 66).10 May 2010: 'Special Fatigue Audit: Jetstar' the 'Cook report' was released (ref links - #219 & PDF 5210KB )26 May 2010: At a 'regular' meeting between John McCormick (former CASA DAS) and Martin Dolan (former ATSB Chief Commissioner), McCormick advised Dolan that in light of the ongoing PelAir parallel investigation, that CASA would be conducting an internal review of it's audit and surveillance processes.(ref link - #97) 27 May 2010: The Hon Anthony Albanese MP and former Minister for Infrastructure, Transport & Regional Development officially opens the REX Australian Airline Pilot Academy. (ref link - #97) 11 June 2010: Correspondence from CASA ALC (assigned legal counsel) Joe Rule to DJ Legal Counsel in reply to questions asked on the DJ FCL suspension in the lead up to a proposed AAT hearing. This 'answering' correspondence would appear to indicate that CASA LSD were also misled in relation to the 0803 AMD TAF. (ref link - #109 & http://auntypru.com/wp-content/uploads/2....6.101.pdf ) 15 June 2010: ATSB receive e-mail from Pel-Air detailing actions done in response toCASA Special Audit.21 July 2010: CAIR 09/3 completed. 28 July 2010: Quote from TSBC peer review report - "On 28 July 2010, CASA briefed the ATSB on the findings of its regulatory investigation into the ditching, which it had done in parallel with the ATSB investigation.Footnote 12 "The team leader obtained a copy of the CASA investigation report in March 2011."1 August 2010: 'Chambers report' created (ref link - #217 ) 18 August 2010: Internal CASA email regarding the discussion with the ATSB over the content of the ATSB report (ref links - #217&PDF 1193KB )11 January 2011: CASA email chain, initiated by Roger Chambers, on Dominic James CEP (Coordinated Enforcement Process) . Highlights one of the many times the CEP was varied and the senior management ranks that had a vested interest in the PelAir ditching matter. (ref link - #98 )18 March 2011: Tabled document received from Senator Xenophon in Canberra. Civil Aviation Safety Authority (CASA) report titled on 'Special Fatigue Audit: Jetstar' (ref links - #219 & PDF 5210KB) 18 March 2011: Pilot Training Inquiry QON asked in the course of public hearing (ref links - #219 & QON 18/03/2011 )March 2011: (see 28 July 2010 ref above)5 August 2011: With little to no fanfare CASA DAS John McCormick issues a regulatory policy directive ( ref link - #74 & Download das-pn015-2010.pdf) titled "ATSB Cooperation Policy". Appears to be a threat to any CASA Officers not to talk out of school to the ATSB. 11 November 2011: Former Pel-Air Chief Pilot and recently appointed CASA FOI(February 2011) Mr. Wickham participates (observer) in a CASA approval process for aPel-Air Check Pilot. Note: Wickham originally applied for a position with CASA as a FlightTraining Examiner in August 2010.26 March 2012: Mr Sangston approves Final Report draft release to the directly involvedparties (DIP) for comment on its factual accuracy. Comments were requested from DIPby 23 April 2012. 24 May 2012: Internal ATSB email- reviewer wanting to look more closely at FRMS and re-interview pilots (ref links - #217& PDF 535KB )24 May 2012: Internal ATSB email- reviewer indicating they can't deviate at this point and they have to work with what they have (ref links - #217 & PDF 360KB )27 March 2012: CASA Delegate Greg Hood signs a 'notice of variation' & 'notice of revocation' correspondence to Dominic James . This notice was supported by, a Hood signed, Roger Chambers authored 'Standard Form Recommendation'. (ref link - http://auntypru.com/wp-content/uploads/2017/10/FOI4.pdf )30 March 2012: Roger Chambers correspondence to CASA (cast of thousands) officers involved in DJ CEP, notifying for administrative purposes the Hood signed 27 March 2012 notice. (ref link - #98 & #100 ) 30 June 2012: Roger Chambers correspondence to DJ notifying him that omission of the agreed conditions on his FCL is illegal and those conditions will now have to be published on his FCL. This notice gave DJ seven days to respond. (ref link - #103 ) 4 July 2012: The ATSB requested a copy of the CASA special audit report under asection 32 notice. A copy of the report was received on 9 July 2012.16 July 2012: Draft 2 issued to DIP.18 July 2012: Roger Chambers recommendation to add conditions to DJ FCL. Included a Roger Chambers authored SFR that was not signed by CASA Delegate. (ref link - #103 & http://auntypru.com/wp-content/uploads/2017/10/Dominic-James-documents-released-19-Oct-17-Volume-1.pdf )July-Aug 2012: REX Airlines declares political donations of 250K to the ALP; 95.7K to the Nationals; & 40K to the Liberals (ref link - http://www.abc.net.au/news/2016-10-24/ae...le/7959394 & #94)6 August 2012: Internal ATSB email regarding the inconsistency in safety knowledge of ATSB staff ( ref links - #217 & PDF 1597KB )8 August 2012: Flight Nurse Karen Casey submits an FOI request with CASA FOI LegalServices Division asking for a copy of the CASA Special Audit Report.16 August 2012: ATSB Commission approve s25 release of Final Report AO-2009-072and officially reclassify the ‘safety issue’ to minor.30 August 2012: ATSB Final Report AO-2009-072 released.31 August 2012: Final Report amended and re-issued.3 September 2012: 4 Corners ‘Crash Landing’ program goes to air 8:30pm.12 September 2012: E-mail chain (Carmody and Dolan) discussing Senator Xenophon’sproposal for a possible Senate Inquiry into the ATSB Final report AO-2009-072 (thetendentious bloggers e-mail).13 September 2012: Senate referred the Aviation Accident Investigations (Pel-Air) tothe Senate Standing Committees on Rural and Regional Affairs and Transport for inquiryand report.26 September 2012: CASA FOI and Finance officer (LSD) Jennifer Smith-Robertsreleases a redacted version of the CASA SAR to Karen Casey.26 September 2012: RRAT committee request ATSB for documents to assist thecommittee with its inquiry.3 October 2012: Reply from ATSB (Dolan) to committee correspondence requestingdocumentation.10 October 2012: Ten documents, including the infamous Chambers Report, were received (presumably sent anonymously) by the RRAT Committee Secretariat in relation to the Senate AAI Inquiry. However these documents were not formally tabled till the day before the extraordinary 15 February 2013 public hearing. (ref link - #24 ) 19 October 2012: ATSB send RRAT Committee correspondence and attachment inresponse to submissions from Aherne, Quinn and Currall, which had been approved bythe committee to be publicly available.22 October 2012: First Public Hearing for Senate ‘Aviation Accident Investigations’Inquiry. 6 March 2014: Senator Xenophon's CAO 48.1 disallowance motion gets voted down in the Senate (ref Hansard: http://parlinfo.aph.gov.au/parlInfo/genp...tion%2Fpdf & http://parlinfo.aph.gov.au/parlInfo/sear...%2F0120%22 ) 10 November 2015: PDF copy of 2010 AO-2009-072 Preliminary report (Aus_Isreal_VH-NGA_18Nov2009_prelim.pdf) is bizarrely modified and added (2126 days after it was created) to the ICAO iSTAR/ADREP database by the ATSB REPCON Manager Elaine Hargreaves. (ref links - 15 February 2010 entry & #56 + https://blogs.crikey.com.au/planetalking.../17/52003/)24 October 2017: The CASA Board has directed that an independent review of the fatigue rules for operators and pilots contained in Civil Aviation Order (CAO) 48.1 Instrument 2013 will be undertaken in 2017 as a result of feedback received from various sections of the aviation industry.30 November 2017: Quote from CASA FOI Officer David Gobbitt correspondence email to Dominic James - "I have not been able to locate a signed copy of the SFR...However, as stated by Adam Anastasi in his email to you dated 27 October 2017, even if the delegate had not signed the SFR, the fact of the delegate sending the decision letter to you on 24 December 2009 would clearly have signified that the delegate accepted the recommendations in the SFR..." (ref - #126 & #331.)

"..Then came the ditching off Norfolk Island. Any serious investigation into systematic flaws would reveal and confirm the worst fears of the ICAO and FAA audits. Although the mystery of two resignations and the decision to discard some fairly important reports is yet to be solved, there remains one curiously intriguing element yet to be satisfactorily resolved. I will leave providing the ‘dots’ up to P2 (patience, patience). I will make a dash toward a conclusion, the reader may make of it what they will..."

This is a long and ongoing tale, so let us begin by setting the scene :

Quote:A series of fatal accidents around the world over the past decade have been linked to pilot fatigue, in response the International Council of Aviation will put in place new rules next year, to manage pilot exhaustion, in one of the biggest shake-ups in 50 years of commercial aviation.

How would react, if you opened the cockpit door and saw both pilots fast asleep! It really happened on a commercial flight.

Such incidents are not the norm, but even these rare occasions need to be managed, as in the aviation industry there is little room for error.

The Australian Transport Safety Bureau concluded after investigating the incident in 1999, when a Qantas 747 overshot the runway at Bangkok, that despite both pilots having been awake for 19 and 21 hours respectively, it was not fatigue related (insufficient evidence)!
Last year, the UN body detailed 26 accidents around the world since 1971 in which fatigue was a factor. Here in Australia, the Transport Safety Bureau has investigated six air safety breaches which have been identified as fatigue related in the past 10 years.

Prof Drew Dawson and Dr Matthew Thomas of the Sleep Research Unit at the University of South Australia conducted an in depth study involving 260 pilots. They wanted to find out how much sleep people were getting as pilots out on the line and we also wanted to know what was the effect of sleep loss on cockpit performance. They found that even though pilots are compliant with the rules, there are a small number of occasions when they aren’t actually getting sufficient sleep to be safe. Pilots who had less than five hours’ sleep were twice as likely to make safety errors.

The incident of this happen is relatively small. “The broader studies which show us that it’s a small percentage, but every day there would be some. It’s in the magnitude of five to 10 per cent who are operating at the five to six hour sleep in the prior 24 hours. So maybe one in 10, maybe one in 20 pilots”. That is still 10 to 20 pilots too many in my book!

Prof Dawson: “The aviation industry in Australia is surprisingly slow to react to the studies report’s recommendations. I think the important issue is to acknowledge the level of risk that fatigue poses and to take an appropriate level of response to it. That is, you don’t wanna shut down the industry, but where there is risk, and we know that there are on occasions a low number of events that carry a high level of risk with them, that we should be able to intervene and manage those in a highly targeted way“.

To put that quite disturbing 7:30 report segment in context, it is worth remembering that it was released 9 days after the FAA IASA audit findings were discussed with CASA:7 December 2009: FAA/ICAO brief on 'next steps' after poor results/findings in the ICAO USOAP 2008 Australian audit. (ref links - [url=http://www.auntypru.com/forum/showthread.php?tid=149&pid=7350#pid7350]#53 & WikiLeaks cable PDF: http://auntypru.com/wp-content/uploads/2...ileaks.pdf
Reflect on this: "...concluded after investigating the incident in 1999, when a Qantas 747 overshot the runway at Bangkok, that despite both pilots having been awake for 19 and 21 hours respectively, it was not fatigue related (insufficient evidence)!.."

& this from McCormick: "..If I was to turn around and say can point to an accident where it 100 per cent was the cause of fatigue, I think I would struggle to find one. Would I turn around and find that fatigue has been a factor in many incidents that have happened, yes, it has been. So fatigue is on our list. It is a high priority..."

MARTIN DOLAN: There was an indication there fatigue may have had a role to play. But the evidence available to us wasn't such that we'd come to the definitive view that there was a major fatigue related element.

JOHN MCCORMICK: In the end it's only the pilot who can decide whether he is fatigued or he or she is fatigued and unable to conduct a flight.

&..

...But there's a document which the Australian public was never meant to see.

It's CASA's special audit of Pel-Air, completed just after the ditching in 2009.

It identifies significant deficiencies within the company's Westwind operations in Pel-Air.

JOHN MCCORMICK: None of those, 31 I think it is, requests for corrective action that we found when we did the in-depth audit of Pel-Air would've affected that accident or prevented that accident.

GEOFF THOMPSON: But given that the operator was failing in areas of fuel planning, fatigue, check and training, lack of support for pilots, and these were regulatory breaches, isn't that something the Australian public has the right to know about, given that that's what the operator was doing when this ditching occurred?

JOHN MCCORMICK: Well as I say, none of those particular incidents or events that we looked at within that audit would've prevented that accident. The accident was caused by poor fuel planning, poor decision making.

Now rewind and this is what former AIPA President Captain Woodward said approximately one month after the ditching:

Quote:RICHARD WOODWARD: The standard answer you get in every accident is 60 per cent or 70 per cent of the accident's caused by the pilots. Well, pilots are human beings; human beings make mistakes, and human beings make lots of mistakes when they're tired.

Five days later Ben Cook and Mal Christie presented their comprehensive scientifically based findings on the CASA approved Pelair FRMS. Extract example from that report (note that the email to Wodger, the 'audit coordinator', was sent the day after the FAA IASA findings were handed down):
Now again let's rewind to exactly a week after the 'inconvenient ditching' to this inconvenient US embassy cable that WikiLeaks also released in August 2011: http://cables.mrkva.eu/cable.php?id=236548

Quote:SUBJECT: FAA'S UPCOMING ASSESSMENT OF AUSTRALIAN CIVIL
AVIATION

REF: STATE 119313

1. (SBU) SUMMARY: Australian aviation authorities will
release a statement on the FAA's upcoming assessment of
Australia's civil aviation, which is scheduled for November
30 - December 4 (reftel). The government release will be out
in the next day and could be in the press as early as Friday,
November 27. Post would appreciate press guidance in case
this becomes an issue. End Summary.

2. (SBU) Terry Farquharson, head of the host delegation from
the Australian Civil Aviation Safety Authority (CASA),
alerted Econoff November 25 that the office of Minister
Albanese (Minister for Infrastructure, Transport, Regional
Development and Local Government, which oversees CASA) had
decided, against CASA's recommendation, to carry out a press
release regarding the upcoming FAA assessment. In the coming
day, CASA will post the statement (a draft of which
Farquharson read to Econoff) on its website and will conduct
an interview with a reporter, with a strong possibility that
an article may appear in the aviation section of "The
Australian" newspaper's Friday edition. It should be noted
that the draft release did not contain anything controversial
and points out that the assessment visit is being conducted
at the request of CASA.

3. (SBU) CASA's view is that the press exposure may
unnecessarily complicate the conduct of the assessment, given
that at its core, the assessment is an attempt to clear the
record from a previous audit in which several shortcoming
were identified (see reftel). The Ministry's office
preferred to carry out the release for the sake of
transparency and in order to preempt after-the-fact
questioning of what the Minister knew or did not know prior
to the FAA teams arrival.

4. (SBU) Comment: We are in close contact with both FAA and
CASA and are facilitating final coordination of the visit.
We do not anticipate this media release will become a
problem, but do expect questions from the press. We would
appreciate press guidance from the Department and/or FAA.

BLEICH

On review of former Minister Albo, CASA, Department and the Australian media archives it would appear that by November 27th the 'powers to be' (Iron Ring) eventually got a rope on Albo as there was no formal MR announcing the imminent arrival of the FAA audit team...

In fact it wasn't till around 8 months later that I can find a passing 'off the cuff' comment by the former Minister for Non-Aviation on the FAA IASA audit: http://anthonyalbanese.com.au/category/m...hes/page/9...CASA, the nation’s independent aviation safety watchdog, will recruit almost 100 additional frontline staff with the $89.9 million in new funding provided by the Budget. This extra investment in safer skies will be funded via a small increase in the aviation fuel excise, from 2.8 cents per litre to 3.5 cents per litre. The Government considers this to be a reasonable and responsible step considering the industry’s continued growth depends on the public’s ongoing confidence in its safety standards. Following the ICAO and FAA audits this investment in CASA’s staff and training is critical, and will strengthen the organisation’s oversight of the industry. Aviation safety should be bi-partisan, and the Government puts the safety of passengers ahead of other interests...
And from the former DAS McCormick there was no mention, that I can find, of the FAA audit findings till nearly a year later in his 'review' contained in the 2009-2010 Annual Report (note there is no mention of the fact that the FAA were three steps away from consigning Australia to CAT II):...A comprehensive training and professional developmentprogram has been put in place to ensure that ourstaff have ongoing training. Technical training wasidentified as an issue by the International Civil AviationOrganization (ICAO) in its 2008 audit and in the USFederal Aviation Administration’s International AviationSafety Assessment (IASA) audit. We have respondedby developing a comprehensive technical training andprofessional development program to enhance staffcapability in areas such as leadership, regulatory skillsand technical expertise...

(P2 comment: Hmm...kind of ironic that in the same year CASA was to lose two of the foremost experts in Australia on aviation Human factors and FRMS/SMS)

Quote from 7:30 report segment: Almost 10 years ago, pilot fatigue was on the radar of the Australian aviation industry. It was the subject of a landmark multi-million dollar study funded by Qantas and supported by the Civil Aviation Safety Authority, Australia's International Pilots' Union and the University of South Australia.

March 11, 2003 05:34 PM Eastern Standard TimeSYDNEY--(BUSINESS WIRE)--March 11, 2003--Qantas, the Civil Aviation Safety Authority (CASA), the Australian and International Pilots Association (AIPA) and the Centre for Sleep Research at the University of South Australia have joined forces to conduct a major study on pilot fatigue with a view to enhancing safety for the traveling public.
The three-year study will set a world first by developing a new risk management-based system for flight crew rostering. This is the first time that an airline, safety regulator, pilots' association and academics have collaborated to find a scientific way of managing the risks associated with fatigue.

Quote:“The FRMS has the potential to be the single biggest improvement in the management of pilot fatigue and rostering since flight time limitations were introduced”Tweet this

The Fatigue Risk Management System (FRMS) study will be conducted in three phases. In the first phase, which is well underway, volunteer flight crew have kept sleep-wake diaries and worn special activity monitors to obtain data on sleep patterns. Over the past 12 months, researchers have collected data on about 4,000 sleep-wake cycles. A further 4,000 sleep-wake cycles of data will be collected over the next 12 months.

In the second phase, as well as collecting sleep-wake data, additional research will be undertaken to determine how quickly pilots' body clocks adapt to changes in time zones.

In the final phase, pilots will be observed in flight simulators to link real performance measures with predicted fatigue.

The research data will then be used to develop methods to determine how different flight tasks are affected by fatigue, and thus be used to determine pilot rosters, shifts and duty time in the cockpit.

Qantas Executive General Manager Aircraft Operations David Forsyth said the study was an exciting development in air safety.

"Qantas has earned a reputation for leading the world in aviation safety and our involvement in this world-class study is a further commitment to improving air safety for our employees and customers."

CASA's Director of Aviation Safety Mick Toller said the study would provide real and lasting improvements in safety.

"This project gives the regulator the first useful access to scientific data to predict when pilots are likely to have lower performance levels due to fatigue. We all know when we are tired, but fatigue is more complex, particularly for pilots doing long flights and operating through numerous time zones most of their working week. Aviation safety will be better for this knowledge."

Professor Drew Dawson, Director of the Centre for Sleep Research, commented that this project is an example of what can be achieved when industry, unions, regulators and the scientific community collaborate to solve problems.

AIPA's Technical and Safety Director Captain Richard Woodward said the study had received enthusiastic support from the pilot research volunteers.

"The FRMS has the potential to be the single biggest improvement in the management of pilot fatigue and rostering since flight time limitations were introduced," he said.

"..Then came the ditching off Norfolk Island. Any serious investigation into systematic flaws would reveal and confirm the worst fears of the ICAO and FAA audits. Although the mystery of two resignations and the decision to discard some fairly important reports is yet to be solved, there remains one curiously intriguing element yet to be satisfactorily resolved. I will leave providing the ‘dots’ up to P2 (patience, patience). I will make a dash toward a conclusion, the reader may make of it what they will..."

This is a long and ongoing tale, so let us begin by setting the scene :

Quote:A series of fatal accidents around the world over the past decade have been linked to pilot fatigue, in response the International Council of Aviation will put in place new rules next year, to manage pilot exhaustion, in one of the biggest shake-ups in 50 years of commercial aviation.

How would react, if you opened the cockpit door and saw both pilots fast asleep! It really happened on a commercial flight.

Such incidents are not the norm, but even these rare occasions need to be managed, as in the aviation industry there is little room for error.

The Australian Transport Safety Bureau concluded after investigating the incident in 1999, when a Qantas 747 overshot the runway at Bangkok, that despite both pilots having been awake for 19 and 21 hours respectively, it was not fatigue related (insufficient evidence)!

Last year, the UN body detailed 26 accidents around the world since 1971 in which fatigue was a factor. Here in Australia, the Transport Safety Bureau has investigated six air safety breaches which have been identified as fatigue related in the past 10 years.

Prof Drew Dawson and Dr Matthew Thomas of the Sleep Research Unit at the University of South Australia conducted an in depth study involving 260 pilots. They wanted to find out how much sleep people were getting as pilots out on the line and we also wanted to know what was the effect of sleep loss on cockpit performance. They found that even though pilots are compliant with the rules, there are a small number of occasions when they aren’t actually getting sufficient sleep to be safe. Pilots who had less than five hours’ sleep were twice as likely to make safety errors.

The incident of this happen is relatively small. “The broader studies which show us that it’s a small percentage, but every day there would be some. It’s in the magnitude of five to 10 per cent who are operating at the five to six hour sleep in the prior 24 hours. So maybe one in 10, maybe one in 20 pilots”. That is still 10 to 20 pilots too many in my book!

Prof Dawson: “The aviation industry in Australia is surprisingly slow to react to the studies report’s recommendations. I think the important issue is to acknowledge the level of risk that fatigue poses and to take an appropriate level of response to it. That is, you don’t wanna shut down the industry, but where there is risk, and we know that there are on occasions a low number of events that carry a high level of risk with them, that we should be able to intervene and manage those in a highly targeted way“.

To put that quite disturbing 7:30 report segment in context, it is worth remembering that it was released 9 days after the FAA IASA audit findings were discussed with CASA:7 December 2009: FAA/ICAO brief on 'next steps' after poor results/findings in the ICAO USOAP 2008 Australian audit. (ref links - [url=http://www.auntypru.com/forum/showthread.php?tid=149&pid=7350#pid7350]#53 & WikiLeaks cable PDF: http://auntypru.com/wp-content/uploads/2...ileaks.pdf
Reflect on this: "...concluded after investigating the incident in 1999, when a Qantas 747 overshot the runway at Bangkok, that despite both pilots having been awake for 19 and 21 hours respectively, it was not fatigue related (insufficient evidence)!.."

& this from McCormick: "..If I was to turn around and say can point to an accident where it 100 per cent was the cause of fatigue, I think I would struggle to find one. Would I turn around and find that fatigue has been a factor in many incidents that have happened, yes, it has been. So fatigue is on our list. It is a high priority..."

MARTIN DOLAN: There was an indication there fatigue may have had a role to play. But the evidence available to us wasn't such that we'd come to the definitive view that there was a major fatigue related element.

JOHN MCCORMICK: In the end it's only the pilot who can decide whether he is fatigued or he or she is fatigued and unable to conduct a flight.

&..

...But there's a document which the Australian public was never meant to see.

It's CASA's special audit of Pel-Air, completed just after the ditching in 2009.

It identifies significant deficiencies within the company's Westwind operations in Pel-Air.

JOHN MCCORMICK: None of those, 31 I think it is, requests for corrective action that we found when we did the in-depth audit of Pel-Air would've affected that accident or prevented that accident.

GEOFF THOMPSON: But given that the operator was failing in areas of fuel planning, fatigue, check and training, lack of support for pilots, and these were regulatory breaches, isn't that something the Australian public has the right to know about, given that that's what the operator was doing when this ditching occurred?

JOHN MCCORMICK: Well as I say, none of those particular incidents or events that we looked at within that audit would've prevented that accident. The accident was caused by poor fuel planning, poor decision making.

Now rewind and this is what former AIPA President Captain Woodward said approximately one month after the ditching:

Quote:RICHARD WOODWARD: The standard answer you get in every accident is 60 per cent or 70 per cent of the accident's caused by the pilots. Well, pilots are human beings; human beings make mistakes, and human beings make lots of mistakes when they're tired.

Five days later Ben Cook and Mal Christie presented their comprehensive scientifically based findings on the CASA approved Pelair FRMS. Extract example from that report (note that the email to Wodger, the 'audit coordinator', was sent the day after the FAA IASA findings were handed down):
Now again let's rewind to exactly a week after the 'inconvenient ditching' to this inconvenient US embassy cable that WikiLeaks also released in August 2011: http://cables.mrkva.eu/cable.php?id=236548

Quote:SUBJECT: FAA'S UPCOMING ASSESSMENT OF AUSTRALIAN CIVIL
AVIATION

REF: STATE 119313

1. (SBU) SUMMARY: Australian aviation authorities will
release a statement on the FAA's upcoming assessment of
Australia's civil aviation, which is scheduled for November
30 - December 4 (reftel). The government release will be out
in the next day and could be in the press as early as Friday,
November 27. Post would appreciate press guidance in case
this becomes an issue. End Summary.

2. (SBU) Terry Farquharson, head of the host delegation from
the Australian Civil Aviation Safety Authority (CASA),
alerted Econoff November 25 that the office of Minister
Albanese (Minister for Infrastructure, Transport, Regional
Development and Local Government, which oversees CASA) had
decided, against CASA's recommendation, to carry out a press
release regarding the upcoming FAA assessment. In the coming
day, CASA will post the statement (a draft of which
Farquharson read to Econoff) on its website and will conduct
an interview with a reporter, with a strong possibility that
an article may appear in the aviation section of "The
Australian" newspaper's Friday edition. It should be noted
that the draft release did not contain anything controversial
and points out that the assessment visit is being conducted
at the request of CASA.

3. (SBU) CASA's view is that the press exposure may
unnecessarily complicate the conduct of the assessment, given
that at its core, the assessment is an attempt to clear the
record from a previous audit in which several shortcoming
were identified (see reftel). The Ministry's office
preferred to carry out the release for the sake of
transparency and in order to preempt after-the-fact
questioning of what the Minister knew or did not know prior
to the FAA teams arrival.

4. (SBU) Comment: We are in close contact with both FAA and
CASA and are facilitating final coordination of the visit.
We do not anticipate this media release will become a
problem, but do expect questions from the press. We would
appreciate press guidance from the Department and/or FAA.

BLEICH

On review of former Minister Albo, CASA, Department and the Australian media archives it would appear that by November 27th the 'powers to be' (Iron Ring) eventually got a rope on Albo as there was no formal MR announcing the imminent arrival of the FAA audit team...

In fact it wasn't till around 8 months later that I can find a passing 'off the cuff' comment by the former Minister for Non-Aviation on the FAA IASA audit: http://anthonyalbanese.com.au/category/m...hes/page/9...CASA, the nation’s independent aviation safety watchdog, will recruit almost 100 additional frontline staff with the $89.9 million in new funding provided by the Budget. This extra investment in safer skies will be funded via a small increase in the aviation fuel excise, from 2.8 cents per litre to 3.5 cents per litre. The Government considers this to be a reasonable and responsible step considering the industry’s continued growth depends on the public’s ongoing confidence in its safety standards. Following the ICAO and FAA audits this investment in CASA’s staff and training is critical, and will strengthen the organisation’s oversight of the industry. Aviation safety should be bi-partisan, and the Government puts the safety of passengers ahead of other interests...
And from the former DAS McCormick there was no mention, that I can find, of the FAA audit findings till nearly a year later in his 'review' contained in the 2009-2010 Annual Report (note there is no mention of the fact that the FAA were three steps away from consigning Australia to CAT II):...A comprehensive training and professional developmentprogram has been put in place to ensure that ourstaff have ongoing training. Technical training wasidentified as an issue by the International Civil AviationOrganization (ICAO) in its 2008 audit and in the USFederal Aviation Administration’s International AviationSafety Assessment (IASA) audit. We have respondedby developing a comprehensive technical training andprofessional development program to enhance staffcapability in areas such as leadership, regulatory skillsand technical expertise...

(P2 comment: Hmm...kind of ironic that in the same year CASA was to lose two of the foremost experts in Australia on aviation Human factors and FRMS/SMS)

Quote from 7:30 report segment: Almost 10 years ago, pilot fatigue was on the radar of the Australian aviation industry. It was the subject of a landmark multi-million dollar study funded by Qantas and supported by the Civil Aviation Safety Authority, Australia's International Pilots' Union and the University of South Australia.

G'Day Aunty, long time reader. Bloody good stuff.

So P2, let me check if a boofhead like me has got a grip on this Pel-Air/FRMS situation mate.

The ïnconvenient ditching" happened bang smack at a time when a new DAS was appointed, the FAA & ICAO were sniffing around and a new airline academy, owned by the "ditched jet"company was goin' on.

FRMS was on the FAA & ICAOs radar from a previous visit. A possible downgrade was on the horizon...then that bloody ditching put a big fat fly in their (CASA) chardonnay!

Experts like Ben Cook (ex-CASA) showed clear evidence that FRMS was an issue within Pel-Air and Aviation in general.

That's when the öh shit" happened within the agencies and the snowball of collusion, corruption & witch hunting started.

Then the bloody first report had no FRMS issues in it & wasn't reported to ICAO. Struth mate, this is serious enough, but it seems to get worse.

The Senate documents (those 9 emails) of more evidence showing what the turds were up to was hidden for 4 months. So the Senators were not able to read them before the inquiry & ask questions. Shit mate, they were only put back on the Senate website less than 24 hours of starting the inquiry. I dunno about you lot reading this stuff, but that is an obstruction of justice. Someone took a big dump on those good Senators. Gotta be a mole from inside.

Albo did nothing, right? His Aviation White paper became Aviation's Invisible paper. I think I saw a picture of him not long after with John Sharp. He's the CEO of Pel-Air. Fancy that, bloody grubs. Albo & John opened the Airline Academy 5 months after the ditching.

Well that makes no bloody sense now, does it. Have a massive screw up then teach the world how to fly. You've gotta be joking!

REX/Pel- Air have a serious incident. So many flaws in their operations. Audit issues coming out of their ears, government investments into the Academy...no wonder the pricks ignored the FRMS problems...would've been the friggin nail in their coffin mate.

REX even donated 300k around the same time the Senate was going on. Albo got a chunk, 100k I think. I mean shit, blind Freddy could figure out what's happening here.

How much money over the eights years has been spent off Tax Payers coin. Gotta be in the millions?

That wingnut Carmody better put his big girl pants on if he is going try & deal with this Snowball of Corruption. They've got no chance of skipping away from this.

The other bloke, Hood...what a tool. He needs to grow a set too. These guys have a shitload of explaining to do. Hopefully in front of the Senators real soon.

Can't see the Senators being impressed with the second report either. Just have to wait & see hey?

Yeah, nah, yeah, nah, yeah, nah, yeah mate. I can see where you're coming from now.

"...The opening gambit is readily seen in the media – see: there’s Hood, doing a Geoffrey Thomas (he of Sunrise fame). This is not a top quality act, but ‘twill suffice. Firstly, we must examine the ‘props’ used, the title for a start will impress – ‘top dog in the Australian Transport Safety Bureau (ATSB) and a natural performer. Always seen looking ‘windswept’ and interesting, dressed in his canary yellow vest, wearing his ‘courage’ wrist band. The ‘shrinks’ would have a field day with that little lot, no matter. The long suffering public will not know the lack of qualification, or the association with some of the most disgusting ‘Acts of bastardy’ which hover about the ‘windswept’ visage. They will have no concept of conflicted interest or even ‘departmental’ manipulations. No; they just see the ‘fluff’ and hear the soothing words, reassured; they happily hop on the cheapest flight and toddle off to booze in Bali..."

"...The main reason being that while HVH was the CASA Executive Officer ultimately overseeing the enforcement actions against both PelAir and Dominic James I also have, on good authority, information that HVH was the designated co-ordinator/liaison officer dealing with the FAA audit team and therefore the consequential cover-up of the actual FAA findings that could have led to the possible Cat II IASA rating..."

So with interest piqued the BRB have tasked me to re-examine the HVH crumb trail with the intent to join some further chronological dots & dashes on the PelAir cover-up timeline (i.e Pel-Air: A coverup: a litany of lies?)...

To begin let's revisit the HVH CV up till the time he started with CASA:Air Traffic Controller

Company Name
Royal Australian Air Force

Dates Employed
1980 – 1990

Employment Duration
•10 yrs

Location
East Sale, Sinai Desert, Darwin, Townsville

Air Traffic Controller

Company Name
Airservices Australia

Dates Employed
Jan 1990 – Apr 1993

Employment Duration
•3 yrs 4 mos

Location
Melbourne Adelaide Alice Springs

Instructor - Centre for Air Traffic Services - University of Tasmania (Launceston)

Company Name
Airservices Australia

Dates Employed
Apr 1993 – Dec 1994

Employment Duration
•1 yr 9 mos

Location
Launceston

Team Leader, Group Leader, FIR Manager

Company Name
Airservices Australia

Dates Employed
Jan 1995 – Mar 2002

Employment Duration
•7 yrs 3 mos

Location
Brisbane ATC Centre

Manager Melbourne Centre

Company Name
Airservices Australia

Dates Employed
Apr 2002 – Dec 2005

Employment Duration
•3 yrs 9 mos

Manager National Towers and Regional Services

Company Name
Airservices Australia

Dates Employed
2006 – 2008

Employment Duration
•2 yrs

Location
Canberra, Australia
As can be seen HVH had all the right pedigree and Quals to continue a long career with progression up the gravy train at ASA. However inexplicably HVH leaves ASA to take up a lesser/nothing position at CASA :

Group General Manager Personnel Licensing Education and Training

Company Name
Civil Aviation Safety Authority

Dates Employed
2008 – 2009

Employment Duration
•1 yr

Location
Canberra, Australia
However with the arrival of McComic in 2009, it would seem HVH's obvious talents (??) were noted by the new DAS and once again Hoody's star was on the rise.

Profile
Mr Greg Hood is a glider and fixed-wing private pilot. He commenced his career as an air traffic controller in the Royal Australian Air Force. His nine years in the military included postings across Australia, and he served with the Australian contingent to the Multinational Force and Observers in the Sinai Desert.

From 1990, Mr Hood spent 17 years with Airservices Australia, in roles including Manager of the Melbourne Air Traffic Control Centre, Manager National Towers and Manager Regional Services.

In 2007, Mr Hood joined CASA as Group General Manager for Personnel Licensing Education and Training, prior to moving to Brisbane to lead the General Aviation Group. In 2009, he was appointed Executive Manager of the Operations Division. In April 2012, he took on the role of Program Director for the newly established Operations Regulations Implementation Division.

Role
Operations Regulations Implementation is responsible for the development, planning and oversight of the regulatory implementation program.

Now remembering that HVH was both the ultimate executioner in the DJ embuggerance case while at the same time the designated liaison officer schmoozing the FAA IASA audit team (till their return in April 2010), the following Oz Flying article on McComic's 1st deckchair shuffle in April 2010 provides some intriguing dots begging to be joined:

At the top of the list, Terry Farquharson has been appointed acting Deputy Director of Aviation Safety, where he’ll support Director of Aviation Safety, John McCormick, in a range of strategic and executive functions. Farquharson will also be directly responsible for a number of areas including accident investigation liaison, the CASA safety management system and Australia’s state safety program.

As part of the restructure, CASA has created the new position of Associate Director of Aviation Safety, which has been given to CASA’s former executive manager, legal services, Jonathan Aleck. Aleck will work with Deputy Director Farquharson to oversee the further development of regulatory and governance policies and practices.

The final changes see Greg Hood appointed as executive manager, operations; Peter Fereday as executive manager, industry permissions; and Gary Harbor as executive manager, corporate services.

McCormick said the changes will form the basis for the further enhancement of safety and regulatory capabilities into the future.

“We now have a strong and focussed leadership team in place which is committed to the goals and priorities which have been established for CASA and its workforce,” said the CASA boss. “Senior managers and staff alike understand the need to deliver on CASA’s core activity of regulating aviation safety, while strengthening safety oversight and surveillance and completing regulatory reform.

“At the same time we are continuing to work on developing more robust governance procedures and practices.”

On another note, CASA has released its latest corporate plan, setting out priorities and initiatives for the next three years.

In realising these goals the regulator says it will strengthen its specialist surveillance staff, determine key safety risks through analysis of data, actively manage delegates and authorised persons to ensure ongoing competence and compliance, take a proactive approach to the shortage of skilled aviation staff, review new regulations and develop and refine appropriate enforcement strategies. Other initiatives cover continuing airspace reform and safer management of flight approaches to aerodromes.

Say what you will about McCormick, but he's clearly keeping busy in the job.

Now fast forward to April 2012 where apparently HVH's job description changed and he became the..

..Program Director for the newly established Operations Regulations Implementation Division..

At the same time he mysteriously departed the scene (MIA) as the ultimate executioner/decision-maker in the DJ embuggerance case:

Quote:

Less than 12 months later (again seemingly inexplicably) HVH leaves CASA to return to ASA...

Via Oz Flying:

Quote:
Greg Hood has left CASA for a position at Airservices Australia, (CASA)

Greg Hood Resigns from CASA
31 January 2013

A key member of the CASA executive team, Executive Manager Greg Hood, is to leave CASA and return to Airservices Australia.

No date has been set for Hood's departure, but CASA has described it as "imminent". His new position at AsA will be as General Manager, Demand and Capacity Management.

In announcing the move, CASA Director of Aviation Safety John McCormick said: "Greg has been an integral part of CASA’s Executive Team over the last six years and I have personally valued his contribution, energy and enthusiasm and I know his management and leadership capabilities have significantly benefited CASA."

Greg Hood is highly thought-of within the general aviation community as a champion for GA, and it is expected his expertise will be missed at the regulator.

Quote:...Rather than ramble on, for the serious student I shall provide just one, solitary link. Fair warning, there are some 37 pages to digest – however; the first dozen or so may be skipped past as they are the written Questions on Notice (QoN) and are repeated as part of the intriguing answers. The questions, standing alone, are incisive; IMO the answers are incredibly revealing...

From two posts above, you may recall that another significant event also occurred on 7 December 2009:

And prior to that date and also in relation to the FAA audit, the Iron Ring (et.al powers to be) successfully managed to muzzle the minister of the Crown responsible for the oversight of aviation safety. The effective muzzling of Albo was only revealed when WikiLeaks leaked the following US Embassy cable nearly 2 years after the event:

Quote:Â¶2. (SBU) Terry Farquharson, head of the host delegation from
the Australian Civil Aviation Safety Authority (CASA),
alerted Econoff November 25 that the office of Minister Albanese (Minister for Infrastructure, Transport, Regional Development and Local Government, which oversees CASA) had decided, against CASA's recommendation, to carry out a press release regarding the upcoming FAA assessment. In the coming
day, CASA will post the statement (a draft of which
Farquharson read to Econoff) on its website and will conduct
an interview with a reporter, with a strong possibility that
an article may appear in the aviation section of "The
Australian" newspaper's Friday edition. It should be noted
that the draft release did not contain anything controversial
and points out that the assessment visit is being conducted
at the request of CASA.

Â¶3. (SBU) CASA's view is that the press exposure may unnecessarily complicate the conduct of the assessment, given that at its core, the assessment is an attempt to clear the record from a previous audit in which several shortcoming were identified (see reftel). The Ministry's office preferred to carry out the release for the sake of transparency and in order to preempt after-the-fact questioning of what the Minister knew or did not know prior to the FAA teams arrival.

Â¶4. (SBU) Comment: We are in close contact with both FAA and
CASA and are facilitating final coordination of the visit.
We do not anticipate this media release will become a
problem, but do expect questions from the press. We would
appreciate press guidance from the Department and/or FAA.

Therefore IMO it would be safe to expect that, as a topic of conversation at least, the very troubling revelation that Australia was (at that point in time) 3 steps away from possibly losing it's Category 1 IASA rating should have figured somewhere in the meeting agenda:

Quote:1. (C/NF) Summary: The FAA team concluded their audit (reftels) and gave a brief assessment of preliminary findings. While the team recognized improvements on previous shortcomings and commended many areas, a few problems remain. Australian officials seem committed to overcoming the shortcomings before a second and final FAA visit within the next three months, but the possibility of a category downgrade does exist and is being taken seriously. The team outlined the sequence of events going forward and agreed to work closely with Embassy Canberra. End Summary.

Now apparently the whole purpose of the CASA Board is to provide independent, effective governance of CASA (the agency) and therefore provide oversight of the administration of aviation safety regulation in Australia. With that in mind you would have thought with the seriousness of the situation, the Board might just have made a press statement in regards to the FAA findings?

Passing Strange - However to this point in time I have not been able to find any evidence that the CASA Board was even aware that the FAA had conducted and completed an audit of CASA 3 days before the 7 December 2009 Board meeting...

And despite mentions in dispatches by former DAS McCormick in his 2009-2010 AR review...

(ref: Pg 10-14)

Quote:Technical training was identified as an issue by the International Civil Aviation
Organization (ICAO) in its 2008 audit and in the US Federal Aviation Administration’s International Aviation Safety Assessment (IASA) audit. We have responded by developing a comprehensive technical training and professional development program to enhance staff capability in areas such as leadership, regulatory skills and technical expertise.
&..

An audit of Australia’s air safety system by the US Federal Aviation Administration’s IASA program confirmed that Australia has retained its Category 1 IASA rating. The FAA was invited by Australia last year to conduct the audit of aviation safety regulation and oversight. Australia’s overall system of aviation safety oversight was found to meet applicable international standards.

...it was not once touched on in the 'message from the Chair', by then Chair Allan Hawke.

Although he did mention the extra funding facilitated by government in the 2010-11 Budget by gouging an extra 4 cent per litre fuel levy from industry, supposedly provided to fix the FAA issues.

Quote:..The Board of CASA has now been in operation for the full year covered by this report. Appointed by the Minister and charged with the principal responsibility of ensuring that CASA conducts its business in a proper, effective and efficient manner, I believe that the Board has partnered and supported the CASA executive team and staff to deliver the
demanding agenda set for the Board by the government.

While CASA’s functions are specified in the Civil Aviation Act 1988, its direction has been set by the 2009 National Aviation Policy Statement (the White Paper) and the 2010
Australian Airspace Policy Statement. The White Paper makes the explicit statement that: ‘…the government is committed to ensuring that it [aviation] remains as safe as it can be. Safety remains the number one priority of the government in aviation’. The Board has therefore approached its tasks mindful not only that safety is the paramount aviation priority of the government, but that the industry must also have this priority as the foundation of their sustainability and future growth.

The Minister has made it clear that CASA needs to be a firm, fair and effective regulator. The announcement of additional funding in the May 2010 Budget was welcome and will be used to strengthen oversight of the industry. CASA’s organisation is now settled and aligned more closely with the Civil Aviation Act and the Board is satisfied that resources are appropriately directed toward CASA’s core functions. The Board has also noted that through the leadership of the Director of Aviation Safety and his executive team, there are now improved governance arrangements designed to provide the foundation for more consistent action and advice to industry concerning the
interpretation and application of legislation...

A subject that I wish to highlight this year is CASA’s achievement in regulatory development. Australia already has exacting aviation regulations, but these must be
continually reviewed, refined and enhanced. This year the Board has reported substantial progress to government in a number of regulatory areas, including the requirement for safety management systems, human factors training for regular public transport operations, drug and alcohol management plans, and the preparation of a new suite of maintenance regulations. We are pleased with these achievements but also aware that the task of ensuring that Australia’s aviation regulations are relevant, effective and aligned with international best practice is an enduring and challenging responsibility. What we consider to be the optimum means of achieving the best possible safety outcomes today will no doubt be succeeded by better approaches in the future...

And an extract from Albo's speech: http://anthonyalbanese.com.au/category/m...hes/page/9...CASA, the nation’s independent aviation safety watchdog, will recruit almost 100 additional frontline staff with the $89.9 million in new funding provided by the Budget. This extra investment in safer skies will be funded via a small increase in the aviation fuel excise, from 2.8 cents per litre to 3.5 cents per litre. The Government considers this to be a reasonable and responsible step considering the industry’s continued growth depends on the public’s ongoing confidence in its safety standards. Following the ICAO and FAA audits this investment in CASA’s staff and training is critical, and will strengthen the organisation’s oversight of the industry. Aviation safety should be bi-partisan, and the Government puts the safety of passengers ahead of other interests...
Reading that load of old codswallop and keeping in mind this extraordinary 'power shot' statement from McCormick in the (above) No.27 AQON...

"...Consistent with the functions of the Board and it's relationship with the Director of Aviation Safety, who has statutory responsibility for all regulatory decision-making, at subsequent Board meetings the Director has continued to keep the Board informed of the high-level changes and internal reforms he had initiated, or intended to initiate, to address operational and organisational improvements, including those cited in the answer to question 25..."

...you begin to get an impression of the untrammelled power that both the Board and the Minister had gifted McCormick, all apparently in the pursuit of achieving the government policy of 'all care but no responsibility' for aviation safety...

Now fast forward to 'here & now' with a different government, a new minister and a professional bureaucrat for a CASA CEO.

Q/ Then ask the question what has changed? Answer: Not much -

Q/ Now ask what happened to the money ($89.9 million back then) that was gouged and continues to be gouged (reportedly +$120 million & climbing) from industry, supposedly to fix the deficiencies discovered in the FAA IASA 2009 audit?

P2 – “Q/ Now ask what happened to the money ($89.9 million back then) that was gouged and continues to be gouged (reportedly +$120 million & climbing) from industry, supposedly to fix the deficiencies discovered in the FAA IASA 2009 audit?”

Amazing is it not; when you think about it. CASA make a total pig’s ear of running ‘aviation’ and the grown ups want it fixed; or else. Yet it is the industry they are buggering up which has to pay for them to fix the major problems. I wonder did CASA contribute to the ‘fix’ by reduced salary and entitlement cuts; or, did the same sad, sloppy, ignorant, arrogant crew just keep doing what they do best (same old) and even manage a salary increase?

Even more amazing is that the Board, still, to this day have no control. In the corporate world a CEO running an organization which had received a shocking audit report would be on the carpet, with the board of directors kicking seven bells out of him. But not in CASA; the grandiosely named DAS can, with impunity, tell the board to sit down, shut up and mind their own damn business. The board must have either have ‘proper’ power and control or; be disbanded, which is favourite - save us all a few bucks. The board is nugatory and therefore redundant. The 'director' has unlimited power - without any tenable checks and tangible balances, it is time that changed.

The whole P2 post above simply demonstrates the depths to which CASA will stoop, their skills in misdirection and subterfuge amply demonstrated and their inflexible reluctance to change. Total power etc. The barn door is wide open, horse has bolted, it’s time to shut the paddock gate.

Can Barnaby reach the gate before it’s all too little, too late. Has Barnaby got the sand to call a Commission of Inquiry; a one where those being looked at do not write the terms of reference; or, will we have another period of Darren6D do nothing?

The Minister appoints the Board and provides the Board with a statement of expectations. The Board is responsible for deciding the objectives, strategies and policies to be followed by CASA and for making sure that CASA performs its functions in a proper, efficient and effective manner.”

Obviously the Board has been incapable of causing CASA to “perform....in a proper, efficient and effective manner.” That is, neither the present Board nor in years past.

If nothing else, CASA’s inability to rewrite the rules after 30 years and counting, would be sufficient for a responsible government to at least question whether there is a structural or systemic problem in the regulation of aviation in Australia. But add to this extraordinary fact the possibility of our aviation world being downgraded by the FAA then surely a new Minister would have reason to make changes. NZ seems to manage it’s international aviation standing pretty well on a fraction of the money we spend on CASA, upwards of $150million pa.

The call for an independent inquiry I understand but do not support. Years ago perhaps, but the Can’tberra dynamic is so incestuous, its become an inquiry factory that generates far more heat than light. The Government appointed “independent umpire” concept, much loved in Australia as a sure fire method of fixing anything is a myth, a comfort blanket approach which diverts responsibility to those who legally cannot exercise it.

Another inquiry would be welcomed by Can’tberra all and sundry with heaps of overtime in the offering, lots of meetings to decide who will represent whom and how. By the time The Inquiry has finished spending and enriching itself and government mulls over the results, forwarding to Directly Involved Persons, the routine, etc., where are we then? Just about where we were one year after the ASRR Forsyth report.

The shocking malaise that infects aviation in this country can only be cured by politicians. There is no substitute for political action, this is the hard yards. Going to meetings, writing, ringing newspapers and MPs. Talkback radio, magazine and article comment. Anything that will give publicity to educate the public and give reason for MPs to want change.

I agree about the Parliamentary inquiries and government reviews. The effectiveness of such inquisitions is completely undone by bureaucratic obfuscation and procrastination, all designed of course to wait out and wear down the significance and urgency of the current inquiries/reviews latest findings and recommendations.

However I believe if the minister/government had the political will to cauterise the CASA Iron Ring and it's malevolent loyal lieutenants, then I think some kind of Judicial inquiry will be required to build a legal case for prosecution of what amounts to decades of ingrained bureaucratic malfeasance that has cost 100s of millions of dollars for no discernible safety benefit to either industry or the air traveling public.

Of course such an inquiry would still take time and money but it is probably a necessary evil if you are to ensure the cancer within has been fully cauterised. After all isn't that exactly what the Kiwis did?

Quote:ATSB and CASA must be disbanded; the Kiwi’s did it very neatly and have never looked back. They reformed the regulator; then the regulations and have set an enviable bench mark for sanity, economy and a way forward ever since. Can anyone see CASA agreeing to that?

&..

Quote:But at the end of the shift – you still have to convince a basically uninterested politician to tangle with CASA and make some radical changes. That politician must be persuaded that ‘the Act’ as it stands is unconstitutional; that CASA is an escaped lunatic and that the blood is not on his hands.

And from your post in response Sandy:

Quote:Secondly it behoves all of us to share and refine our thoughts on what is wrong and to reach some consensus on the method of reform. To this end it is clear that only by a change to the Act can reform occur. In the variety of diverse opinions about specifics, one would be hard pressed to obtain clause by clause complete agreement. Therefore the focus must be on the necessity for legislative change by demonstrating that the current trajectory is one of failure.

Because such an inquiry is being conducted does not mean that the legislative solution (that most believe is required) could not be acted on by the government and parliament, as such legislative changes are a parliamentary process and not subject to Judicial review or the ultimate findings of such an inquiry.